In response to changing policies and market conditions, hospitals must make decisions about how to staff the role of the attending physician since this individual plays a pivotal role in coordinating patient care, including timely and safe discharges that avoid hospital readmission. In 2013, hospitals are now penalized for higher than expected 30-day readmissions rates. In this application, we propose to study 3 paradigmatic illness trajectories among NH residents with severe functional impairment in order to understand how hospitals choose to staff the attending physician role: 1) dementia with advance cognitive; 2) end organ dysfunction from CHF; and 3) hospitalized NH residents with pneumonia with pre-existing severe functional impairment. Dementia is a paradigmatic illness with prolonged severe functional impairment where medical treatment decisions must weigh quantity vs. quality of life. The latter two cohorts challenge health care providers to coordinate care across health care settings to avoid hospital readmissions and to make decisions with the patient and/or family regarding the goals of care. Using the MDS and Medicare claims data from 2000 to 2014, we propose to characterize hospitals' decisions to staff the role of the attending physician (Aim I) and examine the impact of those decisions on clinical outcome and health care utilization experienced by frail elderly, NH residents (Aim II). As of 2013, hospitals are faced with penalties for having a higher than expected 30 day re-hospitalization rates for patients with acute myocardial infarction, congestive heart failure, and pneumonia. Our third aim is to estimate the intended and potential unintended consequence of this new policy. A final fourth aim proposes to conduct 8 case studies to understand how hospitals with higher and lower rates of 30-day readmission organize physician services and coordinate care with the NH medical staff to provide high quality of care for each of these 3 proposed cohorts of frail, older persons. The proposed research will provide policy relevant information to examine observed dramatic changes in characteristics and hospital staffing the role of the attending physician as well as evaluate the impact of ACA penalties for hospitals with higher rates of 30 days hospital readmissions.